Speaking of Psychology - How Psychologists Can Do More to Address the Opioid Crisis (SOP82)

Episode Date: June 5, 2019

Every day in America, 130 people die from overdosing on opioids and an estimated two million people around the country are grappling with opioid addiction and it is devastating families and communities. In the face of these grim statistics, APA CEO Arthur C. Evans Jr., PhD, explains how psychologists can offer new solutions to help end the opioid epidemic, including non-pharmaceutical treatment for pain and other interventions. APA is currently seeking proposals for APA 2020 sessions, learn more at http://convention.apa.org/proposals Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to Speaking of Psychology, a bi-weekly podcast from the American Psychological Association. I'm your host, Caitlin Luna. Every day in America, 130 people die from overdosing on opioids, including prescription pain medication, heroin, and synthetic opioids such as fentanyl. That's according to the National Institute on Drug Abuse. It's estimated that nearly 2 million people around the country are grappling with opioid addiction and its devastating families and communities. In the face of these grim statistics, psychologists are offering new solutions to help end the opioid epidemic, including non-pharmaceutical

treatment for pain and other interventions. The opioid crisis is the topic of a special report in the June 2019 issue of the Monitor on Psychology, APA's magazine for members that covers the science and practice of psychology, as well as how psychology influences society at large. You can read the special report at APA.org slash monitor. Our guest for this episode is APA CEO, Dr. Arthur C. Evans, Jr. Dr. Evans has worked previously in the areas of substance use disorders and addiction, and has approached these issues in a variety of ways.

As a clinician, he's worked directly with individuals providing direct services and case management. He's served as an administrator and program director, where he's overseen treatment programs for people with opioid dependency. He's also worked on studies examining. different types of treatment for substance use disorders and has engaged in many years of policy work focused on substance use addiction and recovery. Most importantly, he's had a family member impacted by substance use problems. Welcome, Dr. Evans. Thank you. I'm very delighted to be here.

The opioid crisis is one of the biggest societal issues the U.S. is dealing with right now. Do you think enough is being done to address it? Actually, I don't think we're doing enough as a nation on this crisis. We have about 130 people dying every day from, from opioid overdoses. And that's just the tip of the iceberg. If you look at the impact on not only the number of people who have a substance use disorder related to opioids, you look at the impact on families, you look at the impact on industry, it is a national emergency.

And I think we have to really not only have a clear national strategy, but we really need to have more resources devoted to this issue. And you've said that APA and its members can be a force for reframing the opioid crisis. What's your vision for how APA can help? Well, absolutely. I, you know, I worked in the substance use field for many years prior to coming to APA. So I worked as an administrator and as a clinician and as a policymaker. And in all of those roles, it becomes very clear that we have to have a different conceptual

of how we think about opioid addiction and how we approach it. And what I mean by that is this is a condition that affects not only people from a physical standpoint and even a mental standpoint, but it affects families. It affects communities. It affects so many aspects of people's lives. And what happens too often is that the solutions to substance use disorders are often focus almost solely on treatment. And one of the things that I know from my experience, and I think the research also supports, is the idea that there are many other aspects, for example,

housing. There are issues related to comorbid, psychological issues that people are dealing with. One of the things we know, for example, is that family intervention turns out to be very important in terms of helping people who have a substance use disorder, yet the typical treatment program rarely includes families in the treatment. So I think that we need to have a broader understanding of what's needed to support people and to help people to be successful. And I think we need to look at the systemic issues that are involved. I'll give you one example of that. one of the major challenges for our treatment systems is the workforce. We have a workforce in the substance use field where you have people who often don't have the level of training that they

need for the complexity of the conditions that they're treating. You have issues of selection and retention of workers. If you go to many treatment programs today and you go to those same programs three years from now, sometimes you'll see as much as a third of the staff have turned over. So if we're trying to attack a major crisis like this, that is one of those issues that we need to address. And so I think one of the things that APA is doing is really trying to reframe how we're thinking about this issue. So we're not only focused on the contributions that we can make as psychologists in terms of treatment, but some of the other areas outside of treatment, and then some of the policy areas like workforce and other policies that are important to address

and treating this condition. So you brought up a lot of great points that I want to touch on throughout the rest of the podcast. And just one thing I wanted to clarify, is when you're saying comorbid, you mean people who have an addiction and also who might have depression or anxiety and other mental health condition, correct?

That's correct. And often these issues are present with people. Sometimes they precede the person's addiction to an opioid, and sometimes they come as a result of having an addiction. addiction. The important point is that if we don't treat it, at the same time we're treating the opioid problem, often people are not successful. And we know that medication is a standard and proven way to treat opioid use disorder, but behavioral interventions can also go a long way to improving treatment outcomes. Can you explain why it's critical to treat the person as a whole?

Well, it's because the addiction affects the whole person and if we're going to be successful with people in treating their addiction, it's important to treat the whole person. I gave the example of family intervention a little while ago, extremely important. And if you think about it like this, a person has a substance use disorder. Over time, what happens is family systems begin to accommodate that person's addiction. So even though the family may not want the person to be addicted, when the person begins to engage in recovery and to change, it really throws the family system out of whack. And so families can unwittingly undermine the recovery of a person if you're not also working with the family. So simply treating the person's substance use condition without thinking about the family system and also treating the family system so that the family system can be. supportive can often get in the way of people being successful. So that's one example of why

we have to have a more comprehensive view of the condition and a more comprehensive set of strategies that we're employing to work with people. I'm sure friends come into the mix too. I mean, if someone who has an opioid use disorder is spending a lot of time with friends with the same issues, changing that and finding new friends is probably another big challenge as well. It is. It's a very good point. And one of the things we know is that social support is a really major resource and for people who are trying to get and engage in recovery. One of the most powerful things that I saw in my career prior to coming to APA is just the power of peer support and people who are walking with people who are going through the recovery. process. That's probably one of the most powerful things that I've seen, even many times more powerful than the treatments that we have available is having that person who's gone through this journey or is going through this journey with you to help you. And so I think that peer

support, which is something that most mental health and substitute systems are really focusing on these days is really important. And I think as a policy issue, we really need to support and fund those kinds of efforts. So I want to talk about more of your previous roles. So before you came to APA two years ago, you were Commissioner of Philadelphia's Department of Behavioral Health and Intellectual Disability Service, a health care agency that's the behavioral and intellectual disability safety net

for 1.5 million Philadelphians. While you were there, you realign the agency's treatment philosophy and services to improve health outcomes. Can you explain more about the work you did there? Well, the work we did was essentially taking some of the things that I've talked about here this morning and really trying to extrapolate them to an entire system. And so one of the major thrusts of our work was to reframe how we thought about addiction and really moved to what's called a recovery management model. And the best way to describe that is this. addiction is often treated as an acute condition.

So the basic model, the mental model that we have for this is that once a person has a substance use disorder, they come to treatment, we treat them, and then we discharge them, and we assume that the person is well. Well, it turns out that substance use disorders are more like a chronic disease, or more like diabetes, where people may have acute symptoms and acute issues. that you have to deal with, but the real success comes when you create a chronic treatment approach where you're providing support for people ongoing. And so a lot of the work that we did was to build that into our treatment system from a policy standpoint. And that made a big difference. We talked

about peer support a little while ago. That's a great support and has helped many millions of people to engage in recovery and to sustain their recovery. Well, the things that we could do as a policy body to support that recovery community and providing that kind of support. We also looked at policies, for example, the length of treatment. So one of the things we know from the research is that essentially the longer you stay engaged in treatment, the better your outcomes are going to be. And 90 days is probably the minimum that people need to really engage in long-term recovery, particularly for people who are going into residential treatment programs. But most people know you have 30-day programs and 45-day programs and 20-day programs.

Well, that doesn't really align with what we know from the science. And so part of what we were doing as well is looking at what does the science tell us that will help ensure that people will have a better chance of recovery. And then let's change our policies to align with that science. And what results did you see when you were the Deputy Commissioner of Connecticut's Department of Mental Health and Addiction Services? Well, in Connecticut, we were going through a very similar process. And in fact, Connecticut was the first state in the country under Dr. Thomas Kirk, also a psychologist who very early on decided that we, wanted to, and he wanted to have a system that was built on certain principles and the kind of

principles that I was talking about. And we really went at, went to looking at how we could do this on a systemic and a policy level. And so it's one of the first systems in the country to really try to do that systematically. And, and that's important because the individual clinician can only do so much. So even if you are a clinician who is very committed, understand the science understands the latest treatment approaches, you have to be in a program and in a treatment environment that is going to support those kinds of approaches. And so, you know, that policy work is really important. And it's one of the things that I think the federal government could really be more helpful in is trying to create a policy environment that supports what we know from the

science works and is best practices. So moving on to APA where I think we'll get into some of that policy. Recently, APA is advocated to nearly double the funding for pain and opioid research at the National Institutes of Health. Can you talk about why research funding is so critical to this issue? It's critical because we don't know a lot of things. So there are a lot of things that we do know about addiction. And in fact, one of the things that I would say, and this is something that a famous

historian in the field, William White talks about, is that we know a lot about addiction, we know a lot less about recovery. And so we need to spend more of our resources understanding what are the mechanisms that really lead to successful recovery, what are the approaches that lead to recovery. We need to study people who are successful in their recovery. One of the things we know is that there are many people who are in recovery who engage in recovery or get into recovery not through the professional treatment system. They go to churches, they go to AA meetings, they go to other resources outside of the treatment system. We need to study that and understand that and to be able to pull that into our armamentarian of strategies that we're using to employ. So that's

one of the reasons that research is so important. But the other is that there are things that that we know are related to people developing substance use disorders, and we need to understand those various pathways. So for example, we know that some people develop substance use disorders, particularly opioid disorders because of they're trying to manage pain. We need to understand those mechanisms much better. We know that some people self-medicate because they're dealing with psychological issues like trauma.

We know that some people may be engaging in their addiction through other mechanisms. And so understanding that, understanding pain's role, understanding how we can intervene earlier is really important and having the research around that is critical for us. Yeah, and those two groups of people you mentioned were explained in the Monitor article, those at-risk groups. How can psychologists help people in those at-risk groups before they develop a substance use disorder. Well, one of the things is to understand who are the people who are at greatest risk

for using or abusing substance use or using opioids. And people, for example, people who catastrophize or people who overestimate the pain that they are actually experiencing, psychologists can assess that. They're actually tools that psychologists can use to assess the people who are more likely to do that. Those people are also people who are more likely. to abuse opioids. And so that kind of assessment, I think, allows us to both on the medical side and on the,

on the substance use treatment side, design interventions that are tailored to a particular person. And I've heard you say about chronic pain that there's no scientific evidence that opioids are the best treatment. So acute pain, yes, but not chronic pain. So I think that was quite surprising, given that how widely opioids are being prescribed. why do you think they're prescribed so often for chronic pain and what all their non-pharmaceutical interventions can help people? Well, I think the fast answer to that question is there's a profit

motive. And I think there have been a number of recent reports on how opioids have been promoted for uses that, for which they were not actually designed. And so I don't think we can, I think we have the fact of that into the part of the equation. But beyond that, I think that there are alternatives. One of the things that health psychologists do in particular is to help people to manage pain in ways that help people to manage their pain in ways that don't require them to use the level of opioids or opioids at all. And that's an important strategy. There are other things that people outside psychology do, whether it's yoga or other kinds of strategies that help people to manage their pain without having to rely on medications. And that's going to be important.

We have millions of people who are currently addicted to opioids in this country. Many of them are addicted because of their attempts to manage pain. And if we're going to get ahead of this issue, we need to look at a variety of ways of helping people to manage pain without medication or at least using less medication. And AP is also working to implement a new law that will expand treatment. Can you explain more about this law? Well, there's several laws that are designed to help expand treatment. Some of them are expanding services like telehealth.

They're making it easier to do those kinds of services. We know in particularly in rural communities, there are often a lack of professional. to help people, and we want to make sure that there are professionals that can help, and people can have access to those folks. So much of the work that we're doing is really trying to make sure that those kind of services are available. We're also very interested in policies that support things like housing. We know that housing is a very important component to a person's resources that they need for recovery.

And it's something that is often not available to people yet really critical. And so our advocacy is around those things that we know from the research or from the science are critical to supporting people. And I definitely want to touch on the housing first idea, which it means that people with substance use disorders or those in recovery are given a safe place to live through subsidies. And a few were noted in the Monitor article that are being led by psychologists. They were the Heart Center in Seattle and Elm City communities in New Haven, Connecticut. Why do you think psychologists are good choice to lead these programs?

Well, I think that one of the skills that psychologist brings is their ability to assess behavior, their ability to design treatment programs or treatment strategies. And one of the things, much of the housing first work is done for people who are homeless. So if a person is living on the streets, they have a substitute disorder, they have a mental health condition traditionally and historically what we would have done is to try to help the person get into recovery first and then go into housing. What the housing first model does is kind of turns that on its head. And it says the first strategy is to get the person stable in housing and then have the services come to the person in supported housing. And that turns out to be a very effective strategy, particularly for people who have serious mental illnesses, but also for people who have certain substance use disorders as well.

And I think that psychologists can be very helpful in that process because many of the people who have substance use disorders and often comorbid with mental health issues who are homeless is that you really need a good assessment of what's going on with a person and you need to design and tailor the treatment and supports for that particular person. And that's an area where psychologists, I think, are really strong. And I'm sure it's more helpful to have people in a home as opposed to a treatment facility. It might just have a different feel and people might feel more comfortable if they're in a place where they know they'll be staying. Stability is very important.

If you just think, if we personalize and think about ourselves, if we don't have a home to go to at the end of the day, it's very destabilizing. And if you're trying to recover from a substance use disorder, it's very, very difficult to do that if you don't have stable housing. And people with opioid use disorder often end up in the criminal justice system. And there are drug courts where judges supervise every aspect of treatment and recovery. And they're being seen as more often as a better alternative. You know, where do psychologists fit into this work? Well, you know, just to understand the role of drug courts, you know, one of the things, one of the misnomer's or one of the myths in the field is that people

have to want to engage in recovery. That's just not true. And the reason that we know that that's not true is from the research that shows that whether people come into treatment voluntarily or involuntarily, the treatment outcomes are roughly the same. And so drug courts turn out to be a really important part of our overall strategy because what they do is that they really force some people who are not ready to engage in treatment. They are literally mandated to go to treatment or they go to jail and most people take treatment over jail. And so what we know is that those programs can be very effective. And I think psychologists can play a number of roles there.

Assessment as we talked about earlier is a really important role. Also understanding the the, the co-modelial. morbid mental health issues. And I think that's really important. Many of the people who end up in court often have a very long history of substance use. And they have many complicated issues around their substance use. And I think to the degree that we can get a better handle on what those issues are and target our interventions, we're going to have a much better shot at those people are going to have a much better shot at long-term recovery. And I think that that's a really important role that psychologists can play in that setting.

And there's definitely a lot of stigma around people who have opioid use disorder. I probably would say it's fairly common. Do you think it stops people from seeking help and does it hinder recovery? I think it really prevents people from getting the help that they need. I think it plays out in lots of different ways. I think one is that it plays out in that people don't reach out for the help that need because they're embarrassed, they're ashamed. And but it also affects the policies that we have.

I think, you know, where we started this interview is talking about is the country doing enough? Well, I think one of the reasons that we're not doing enough is because of the stigma associated with substance use disorders. If this were, you know, we had 130 people dying every day from practically any other health condition, I think this country would be really focused on. addressing that and the fact that we're not, I think it has a, that stigma has a lot to do with the fact that we're not. So I think it's something that we have to deal with in my previous work in both Connecticut and in Philadelphia, we spent a good bit of time thinking about the

issue of stigma and how to address that. One of the things that happens in, from a policy standpoint, is that policymakers are often so focused on service delivery, they're not thinking about the issue of stigma. And they're certainly not using resources to address that issue. But one of the things I would say quite often is that it doesn't matter if we have the best treatment programs in the country and they're the most effective

if people don't come to them. And so we have to, as we're building capacity, we also have to think about how do we help help the, how do we help reduce the stigma so that people will actually reach out for help, that family members and coworkers will know how to help support people and to get them connected to services. And that has to be a part of our overall strategy. So it's something that I think APA can be very involved in. And it's something that I'm really looking forward to us playing a more, a greater leadership role in. Do you think the stigma is lessening a little bit because a lot of

stories I've read in the news feature, you know, people from all walks of life who've been grappling with addiction. It seems like every corner of America has been affected by this crisis. I think stigma is being reduced. One metric that I used in my previous work, you know, we had a recovery walk in Philadelphia that started with 150 people. These are mostly people who are in recovery and sort of like the breast cancer walks. People are coming out. to put a face on recovery. You know, you go to that walk today, it's, you know, it's almost 30,000 people.

And over half of that group, well over half that group, are people who are in recovery. So people are much more willing today to be public about their recovery. You know, one of the things I really like about the recovery movement that's happening around the country now is that, you know, when I came into the field, anonymity was really the way that

It was really the way people dealt with their recovery. And so, you know, people wouldn't disclose. Today, I love it when I go to an event and someone says, you know, hi, I'm Bob. I've been in long-term recovery for 20 years. And that means I haven't taken a drink or a drug in the last 20 years. And they explain what that means. And here's Bob, who's in a suit, who's this successful business executive or lawyer or whoever he is. is, and he's being very public about that.

The public sees people who are addicted all the time. They see how that plays out. What they don't see are the people around them who are in recovery, who've been successful. And so the more people talk about that, the more, I believe, it reduces stigma. And I hope, you know, 10 years from now we'll be having a different conversation about this, that we've actually moved the Dow

to such a degree that we have policies and we have people who are educated in our communities who can really help those of us who are struggling with addiction. I think words can matter a lot in terms of how we describe people with opioid use disorder. You know, for instance, instead of calling someone a drug addict, we would say a person living with addiction or a person with substance use disorder. Do you think that helps to lessen the stigmas in terms of like the language we use? I think it's very important. And I hope that every single person listening today and to this podcast will make a commitment

not to use the word addict. I think it is very stigmatizing. It sounds like a condition that people can't get over. And I understand why, you know, particularly many of the self-help groups that people use that because what they were essentially saying is, look, once you have an addiction, you have that, you know, throughout your life and you have to manage that. I get that, but using that terminology, I think, stigmatizes people. That's why I really like people who talk about, you know, I'm Bob, I'm a person in long-term recovery. Same, you know, same condition, but I think that gives a very,

gives a public a very different understanding of what this is about in terms of being in recovery. And in terms of prevention, I know we've touched on this a little bit throughout the podcast, but can you explain a little more where psychologists fit into that? So is that addressing some of these other mental health issues before they turn into a substance use disorder? Yeah, I think it's all of that. I think that people develop addictions different ways through different pathways. And I think psychologists who can help identify those pathways, are really important to our overall set of strategies.

So understanding pain and being able to prevent people from, or at least identifying that people were at highest risk is actually a really good strategy for reducing the likelihood that someone is going to become addicted to pain medication. Addressing trauma, trauma actually turns out to be an issue that we find to a very high degree in people who have substance use conditions. And to the degree that we are identifying that early on and using evidence-based treatment approaches that have been developed by psychologists,

that is an important strategy in reducing the likelihood that people will self-medicate to manage their trauma. I think that there are other ways that psychologists can be very helpful in terms of early identification. You know, I have some colleagues who are health psychologists and they work with people who are suffering from pain and often those individuals have not only pain, but they have depression, they have anxiety, they have a number of conditions. And I think if we can get in there earlier and treat the whole person, treat all of those

conditions and not treat them as sort of these independent separate issues, that we're going to have a much better chance of helping people and preventing them from developing long. term substance use disorders. And as we've discussed, you've had a lot of experience working with state and city governments. What do you think psychologists can do at both the local level and the state level? On the one hand, I think it's important for psychologists to be actively engaged in direct services, and that's what we're trained to do, many of us who are clinically trained to do that work. but I also think it's really important for psychologists to be much more involved in administration and in

policy making. And the reason is that psychologists bring a unique perspective to that work. Psychologists are trained as both scientists and as clinicians. And I can tell you from my work in working in public policy, you have to, having a scientific background and foundation in your work is really important. When you start to set policies for tens of thousands of people, you don't want to do that by anecdote. And often you see too many policies that are based on a limited set of experiences, but that's the experiences that the policymaker has been exposed to. You know, psychologist's training and having experience in looking at data and using data and using research are really important in developing policies that are much more grounded and much more grounded in research,

but also policies that will have the greatest impact and will have reached the most people, but also be the policies that are having the most impact in terms of what we're trying to accomplish. So I think that that training and that perspective is a very important aspect. You know, other disciplines have other perspectives. and skills that they bring. And I think that that's important. But I do think that there is a unique role for people who are trained as both scientists and practitioners and being able to bridge the clinical policies with the research and the science.

And as we discussed some of the programs you've been involved with in Philadelphia and Connecticut that are recovery first models and they also involve the full family and friends into the picture, do you think those can be serve as models for addressing the opioid crisis? in other states and cities, or have they been already? They have been, and there are more and more people, not only in the United States, but literally around the world. I've spoken in Australia, New Zealand, and Sweden, and lots of different places around the world.

And I think we all are dealing with the same issues. We are dealing, you know, the way substance use disorders play out in Philadelphia or Washington, D.C. or Stockholm, pretty much the same. And we know some things from the research and from our experience about what are effective policies. And so I think it's really important for us to have ways of sharing our lessons earned. I think it's one of the roles that APA can play, which is as a convener of people from different places, from different disciplines coming together, sharing what we've learned that has worked. and then trying to replicate that in places around the country. Bringing this back to the federal level, APAs also provided expert input for the President's

Commission on Combating Drug Addiction in the Opioid Crisis. Can you talk about what APA said in that? Well, I think the one thing that we said that was really important was that we have to take a comprehensive approach to this issue. We need to advance non-pharmacological interventions for pain. we need to make sure that we are funding these kinds of services adequately. And we need to really, one of the things that we really need to do is to make sure that we're addressing issues like workforce and other kinds of policies that are important in terms of creating a comprehensive system. And you talked about what you hope to see in 10 years from now as terms of how we see people who are having substance use disorders.

What is your hope in the next year or five years or ten years in terms of what we're seeing around the country with the opioid epidemic? Well, I would hope that we are at a place in this country where the stigma is much less and that people are willing to engage in treatment. I would hope that there were more people who were talking about their journey of recovery. I would hope that we would have policymakers that were more informed. You know, those who are in the executive branch and who are the experts to lead federal agencies and state agencies are one thing, and they have a certain level of understanding. But legislators make a lot of policies. They determine funding levels.

They make the laws. And we need to make sure that those folks have the knowledge and understanding of what it takes for a good comprehensive system. And I would hope that over the next 10 years, we, APA, could be very involved in helping to educate those legislators and policymakers so that they can make better decisions about how we address these issues. Thank you so much for joining us, Dr. Evans. It's been a really thought-provoking discussion about the opioid epidemic and the role of psychology. Thank you. I've enjoyed it. If you're a psychologist and interested in learning more about how you can get involved in helping address the opioid epidemic, the Monitor's Special Report has a lot of great resources. Be sure to also check out our episode from November 2018 called Using Psychology for Pain Relief and Opioid Reduction with guest Dr. Beth Darnall of Stanford University. It focused on the millions of Americans using opioids to manage chronic pain and how psychology and mindfulness can treat them and help people with chronic pain live better lives.

You can find that episode on iTunes, Stitcher, or wherever you get your podcasts. It's also posted on Speaking of Psychology.org. Before we go, just a reminder to let you know we want to hear from you. You can email me your comments and ideas to K-Luna at APA.org. That's K-L-U-N-A-A-A-P-A-R. Also, please consider giving us a rating in iTunes. We'd really appreciate it. Speaking of Psychology is part of the APA Podcast Network,

which includes other great podcasts like APA Journal's Dialogue about new psychological research and progress notes about the practice of psychology. You can find all of our podcasts on iTunes, Stitcher, or wherever you get your podcasts. You can also go to our website, speakingof psychology.org, to listen to more episodes. I'm Caitlin Luna with the American Psychological Association.